January 10, 2019
Despite an opioid crisis, most ERs don't offer addiction treatment.
California is changing that
<https://www.vox.com/future-perfect/2019/1/8/18099534/opioid-epidemic-addict
ion-treatment-emergency-room-er-california> Vox
By German Lopez
SACRAMENTO, California - When Michael Curci still used opioid painkillers
and heroin, he didn't see himself living beyond his mid-20s.
"I didn't even think I was going to make it," Curci told me, while at the El
Dorado County clinic where he receives treatment for opioid addiction. "I
didn't think I was going to have any type of future."
Curci is now 28. The moment that helped him survive came in October 2017,
when he went to an emergency room not due to an overdose or an
injection-related infection but to seek treatment for addiction. Unlike most
hospitals in the US, Marshall Medical Center, an hour's drive east of
Sacramento, provided him with real treatment - particularly, buprenorphine,
a highly effective medication that treats opioid addiction by mitigating
withdrawal and cravings for the drugs.
For Curci, the approach has worked - after years of drug use, parties,
doctor-shopping to get painkiller prescriptions, and even prison time due to
two robberies meant to help get money for more drugs. There have been
setbacks and one brief relapse since Curci got into treatment, but "now I
know I'm going to have a future," he said. "Now I know that I can do these
types of things. I can have a job. I can do whatever I want with my life."
If Curci had gone to the emergency room at most other American hospitals,
his story might have ended differently. Patients in ERs with other chronic
conditions, like heart disease or diabetes, typically meet with a specialist
quickly to start the long-term process of managing their condition. A
patient with drug addiction, on the other hand, is often sent on his way
with a pamphlet for treatment options, a few talking points, and not much
else - even though the evidence suggests that this hands-off approach does
little to reduce the serious risk of overdose and death.
Curci, though, encountered a still-unusual approach of treating addiction in
the emergency room - one that California, Massachusetts, and other states
are now expanding in earnest as the country deals with an opioid epidemic.
At the core of this work is a straightforward idea: treating addiction like
any other medical condition, and building treatment for addiction into the
rest of the health care system.
If done right, this idea could dramatically expand access to addiction
treatment across the US. Instead of relying on expensive, infrequent, and
siloed addiction treatment facilities, people with addiction could go to
their doctor or local hospital to get help. They could pay for that
treatment not out-of-pocket - as remains common - but with health insurance,
making treatment much more affordable. The medication they use would be
viewed not as a crutch - a common view of buprenorphine - but as akin to
insulin, aspirin, or any other medication for chronic conditions. And as
with other conditions (from diabetes to cancer to heart disease), relapse
wouldn't be treated as a moral failure, but a normal part of recovery.
The ER is one place where this broader approach can begin. Most emergency
rooms across the country, though, do not offer this care. Much of that is
caused by stigma toward drug use and addiction, which can make it difficult
to persuade ER doctors to do something they historically haven't done. But
even if health care providers do want to offer addiction treatment, there
are concerns: How do you do it? Will it be expensive? Where will patients go
for continuing care after they leave the emergency department, especially in
a country where treatment options are often inaccessible or nonexistent?
California and other states' experiences, though, suggest an ER addiction
treatment program isn't only possible, but that it works. California is now
gearing up to expand the idea, with the state's Bridge Program and Public
Health Institute gearing up to award more than $8 million to as many as 30
hospitals in the coming weeks. By making treatment more like other kinds of
health care, the state is hoping to see more stories like Curci's.
As America's opioid epidemic continues, the approach is increasingly
necessary. Drug overdoses were linked to a record 70,000 deaths in 2017,
more than two-thirds of which involved opioids, and 2018 appears to have
been about as bad. And beyond the overdose deaths, federal surveys have
found that there are more than 2 million people addicted to opioids in the
US - and experts say that is, if anything, an underestimate. Those are
millions of people who could potentially benefit from treatment if it's made
more available.
Filling America's addiction treatment gap:
Most people in the US with drug addictions struggle to get treatment. A 2016
surgeon general report found that just 10 percent of people with a substance
use disorder get specialty treatment, in large part due to a lack of access
to care. Even when specialty treatment is available, federal data indicates
that fewer than half of treatment facilities provide evidence-backed
medications like buprenorphine or methadone.
These medications have been around for decades. Studies show that they
reduce the all-cause mortality rate among opioid addiction patients by half
or more and do a far better job of keeping people in treatment than
non-medication approaches.
But misconceptions remain about buprenorphine and methadone, in large part
because they are opioids themselves. Curci himself told me that he worried
the medication was just "substituting one drug with another." But the
problem with addiction isn't that someone is using drugs or even opioids.
The problem is when drug use turns compulsive and harmful, leading to health
problems, broken relationships, crime, and other negative consequences. So
if buprenorphine or methadone helps someone stabilize his life, as was true
in Curci's case, then the medications really do treat the addiction even if
they're taken indefinitely.
But as the federal data indicates, these medications remain difficult to get
in America.
In theory, health care providers can prescribe buprenorphine, but not many
do. According to the White House opioid commission's 2017 report, 47 percent
of US counties - and 72 percent of the most rural counties - have no
physicians who can prescribe buprenorphine. Only about 5 percent of the
nation's doctors are licensed to prescribe buprenorphine. And if a health
care provider does want to get certified, the process can be time-consuming
- requiring, under federal law, a special training course that's eight hours
for doctors and 24 hours for nurse practitioners and physician assistants.
Methadone is similarly inaccessible. It's siloed off into special clinics,
which face arduous federal, state, and local regulations, and are frequently
forced to operate in low-income and minority neighborhoods due to
not-in-my-backyard attitudes. Many places don't have any methadone clinics
at all - including El Dorado County, where Curci got help at Marshall.
Traditional addiction treatment clinics can also offer the medications, but,
based on the federal data, the majority don't. That's a result of the kind
of stigma Curci previously held: Despite the evidence of effectiveness, many
traditional addiction treatment programs don't see people as genuinely in
recovery if they use buprenorphine or methadone.
The opioid epidemic, however, has led policymakers and people in addiction
treatment to reevaluate the evidence and to try to dramatically expand
access to addiction treatment. That's now extended to ER-based solutions.
The idea is not that someone has to come into the ER through an overdose or
injection-related infection to start getting into treatment. As Arianna
Sampson, who helped set up the ER program at Marshall Medical Center, told
me, the possibility of withdrawal - which is characterized by terrible
flu-like symptoms, along with crippling anxiety - is enough of an emergency
to start getting people into treatment. In short: If someone wants help,
they can get it at the ER 24/7.
"We have an open door," Sampson said.
Seeking help at the ER:
One patient, whom I'll call Claire, went to the the UC Davis Medical Center
in Sacramento in withdrawal and wanted to start on buprenorphine for her
opioid addiction. At 48, Claire had most recently been using opioids for
five years, though she had struggled with drug use for much of her life.
Claire carried around a large bag, which, among other items, held phones
that she played games on to distract herself from the withdrawal pain that
she was currently going through. Asked where she felt the pain, she
responded, "Everywhere." On a scale of 1 to 10, she rated her pain an 11.
Claire found out about the ER program through its substance use counselor,
Tommie Trevino. But when she showed up, she was skeptical it would work.
"I'm in withdrawal," she said. "I'm scared it's not going to be enough."
The UC Davis ER staff checked her vital signs and asked her about her
previous medical history, which included pancreatitis, hepatitis C, and a
fractured back. They asked when she last used heroin, since buprenorphine
requires at least partial withdrawal to work. Claire said she had last used
at 8 pm, a bit over 14 hours before she showed up at the ER. That's enough
time for withdrawal.
In between doctor and nurse check-ins, Claire opened up to Trevino about
struggling with addiction, an abusive husband, and better times before she
fell down into heroin use once again. She complained about the withdrawal
pain, which she said was causing her to hurt all over her body. She talked
about her 5-year-old granddaughter. "She's my life," Claire said. She joked,
"I don't even like my kids anymore."
A nurse gave Claire a first dose of buprenorphine, then, when it wasn't
enough (which is pretty typical), another dose. Within an hour, Claire was
relaxed. Her heart rate calmed. When she first came in, Claire was restless
and in pain, refusing food because she was nauseated from withdrawal. Now
she could sleep. She said she was hungry and got a sandwich shortly before
she left.
"That stuff works pretty fast," Trevino said.
By the time Claire left, she had begun setting goals for her recovery and
said she felt "great" and was "grateful" for the chance to get treatment.
There is growing evidence for the ER approach:
Watching the ER visits, the most striking thing about them was how normal
they were and how much the clinicians involved simply treated addiction like
any other health problem. Patients had their vital signs taken. Doctors and
nurses checked for other medical needs. Patients got other care as
necessary. The discussion about addiction, too, seemed largely like any
other doctor's visit - with a back-and-forth about the patient's problems
and desires, and how that could be balanced out with what the health care
provider considers best.
This is not how America has, by and large, confronted addiction in the past.
Addiction has notoriously been characterized as a moral failure. The most
common response I get to any addiction story argues that overdoses are just
"Darwin's theory in action."
A growing body of scientific evidence, though, shows that this has never
been the right way to approach addiction, and addiction should instead be
treated much like the ER visits that I witnessed.
One big study, published in JAMA in 2015, randomized participants at Yale
New Haven Hospital in Connecticut into a more typical ER approach for
addiction that referred patients to treatment elsewhere, another approach
that tried to more directly motivate patients to seek treatment, or
buprenorphine treatment. A month in, the patients who got on buprenorphine
treatment in the ER were around twice as likely to remain in addiction
treatment compared to other participants, and reported less than half the
days of illicit opioid use per week as the other groups.
A follow-up study published in Addiction in 2017 also concluded that
buprenorphine treatment is cost-effective compared to other approaches.
One hitch to the initial study: While buprenorphine patients reported less
illicit opioid use per week, all patients - regardless of approach - were
about as likely to test positive for opioids in urine tests.
Gail D'Onofrio, lead researcher on the study, argued that this doesn't mean
that the buprenorphine treatment was less effective, because urine tests can
pick up opioid use from days ago. So if someone has reduced their opioid use
but is still using to a lesser degree - still a welcome, if imperfect,
development - that wouldn't show up with a urine test, but it would in the
self-reports.
D'Onofrio did caution, though, that the study's promising results don't
necessarily mean that the ER approach will work everywhere. Yale's hospital,
which is highly respected and connected to a lot of local treatment
resources, may be able to do this kind of work better than most others.
(Even the standard, referral-only approach that the study used was more
extensive than what most ERs do.) The same might not be true in other parts
of the country.
So research will likely need to validate the approach in other areas. Some
of the people involved in California's work - along with the National
Institute on Drug Abuse, a federal agency - are working to produce those
studies. But there's good reason to think it'll work, given the Yale study
and the overall evidence behind buprenorphine.
Treatment is needed after the ER, too
The hardest part of getting addiction treatment in the emergency department
may not be anything in the ER itself. Instead, leaders of ER programs in
different states told me that the biggest hurdle may be ensuring that a
patient has a place to get longer-term care after the ER starts that patient
on addiction treatment.
At the UC Davis emergency room, Claire left with a buprenorphine
prescription to tide her over, and staff set up an appointment with a county
clinic for low-income patients like her that can usually see new patients
within a week.
It was, Trevino told me, the typical process: A patient comes in with
withdrawal, overdose, or an injection-related infection; gets started on
medication treatment; and is set up with another health care provider for
longer-term care.
A bit east, at Marshall Medical Center, it was the same process that Curci
went through when he was referred to El Dorado Community Health Centers,
where he's still a regular patient. It's what anyone would expect from the
ER with any other medical condition.
But longer-term care is a thorny problem. Even if an ER starts people on
addiction treatment, it's possible, even likely, that there won't be a
treatment clinic around, or a clinic will have a waiting period of weeks or
months. It's the equivalent to having the ER stabilize someone with a heart
attack and giving them some short-term medication, but there being no
cardiologists or other specialists around for follow-up care.
This is one of the most common concerns that ER health care providers raise
about offering addiction treatment, said Sarah Wakeman, an addiction doctor
and the medical director at the Massachusetts General Hospital Substance Use
Disorder Initiative. As Massachusetts, one of the states hardest hit by the
opioid crisis, has enacted legislation to get more ERs to do opioid
addiction treatment, a lot of its focus has gone to making sure there is a
source for follow-up care. But the process of rolling out this legislation
and related programs hasn't been easy.
"It was a tough sell to get the emergency medicine doctors interested in or
excited about getting waivered for buprenorphine without knowing what would
come after the ED," she explained.
Overcoming that hurdle has required linking existing addiction treatment
providers, who needed to coordinate with each other to work more efficiently
and take in more patients overall. But in some cases, the existing pool of
providers wasn't enough, so new clinics or providers had to be established
from the ground up.
In California, the same concerns were raised. Much of the work in Sacramento
has focused on simply finding more addiction treatment providers and clinics
to follow up with patients, said Aimee Moulin, who's helped set up the ER
program at UC Davis Medical Center.
One of the clinics the ER partnered with in Sacramento, Transitions Clinic,
has an incredible backstory: Its founder, Neil Flynn, was on the front lines
of HIV/AIDS during the height of that epidemic in the 1980s and '90s. As he
saw some of his HIV patients get addicted to opioid painkillers and as the
opioid crisis worsened, he moved to the front lines of another epidemic, got
certified to prescribe buprenorphine, and began treating addiction.
When I asked what buprenorphine treatment had done for them, patients at
appointment after appointment at Transitions all said the same thing: "It
changed my life." They told me about how now they could attend to their
families, maintain a job, and get back to other interests. One patient was
very excited she had been hired for a voice acting gig for a major video
game company.
But all this came at a steep cost for patients: $200 per month. Transitions
does not accept insurance.
The $200 a month paid for as many appointments as patients needed. When I
was there, Flynn often told someone to come for a follow-up a week later,
free of charge. But it still came down to $200 a month, completely out of
pocket.
If he took insurance, Flynn said, there's a good chance that his clinic -
which was barely breaking even, he emphasized - would actually lose money,
because health insurance didn't pay much, and he'd have new expenses, such
as hiring staff for billing and working with insurance companies. That's a
common problem with addiction treatment, for which insurance reimbursement
rates are often low.
But $200 a month is a lot to ask for, particularly for people with opioid
addiction who may not have been able to keep a job due to their illness. The
good news is insurance will pay for the buprenorphine itself when a patient
goes to pick it up at the pharmacy, but that doesn't cover the other
expenses.
Moulin and Trevino acknowledged the problems with Transitions. But they
noted that Transitions had a big advantage: It could take patients within a
couple days. The other partner that UC Davis worked with, a county clinic,
did accept insurance, particularly Medi-Cal (California's equivalent of
Medicaid), but it typically could only see patients after a wait time of a
week. Claire, as someone who's jobless and on Medi-Cal, had to go to the
county clinic.
This is the difficulty of finding partners, particularly in rural regions
but even in some well-resourced areas like Sacramento: The options can be so
scarce that pros and cons have to be worked around, with providers left
hoping that someone or something else - like, say, a federal infusion of
funding - will help finally solve the underlying problems that lead to too
few addiction treatment providers.
Wakeman argued for another solution: getting more traditional health care
providers certified to prescribe buprenorphine. Under federal law, doctors,
nurse practitioners, and physician assistants can obtain a waiver to
prescribe buprenorphine. But it requires a special training course, meaning
health care providers must be committed to doing this. If they do it,
though, they could help dramatically expand access to opioid addiction care.
The integration of addiction treatment into health care
At the core of all the ER work is a straightforward idea: treating addiction
like any other medical condition and building treatment for addiction into
the rest of the health care system.
When I asked Moulin how she saw her own role in California's ER program, she
responded, "At the heart of it, I'm just an ER doctor." This is how she
wishes other people saw this work: that treating addiction is simply part of
the job of working in health care.
The major hurdles to accomplishing that, Moulin and others told me, are a
mix of stigma, misconceptions about addiction, and institutional inertia.
The modern understanding of addiction stresses treating addiction as a
medical condition, with social and environmental contributors. But even
among doctors, it's still very common that people perceive addiction not as
a medical condition, but as a moral failure. Some health care providers also
question why they should care about addiction, given that they typically
haven't had to in the past. Both biases can be overcome with education - but
they are lingering problems.
Other providers worry that treating addiction will cause patients with
substance use disorder to flood their offices and clinics. But this,
D'Onofrio of Yale said, misunderstands the reality: "They are already in
your ED, because they're there with withdrawal or other complications. . In
fact, you got a good chance you're going to reduce your ED visits once you
get them into treatment."
Another problem that Moulin pointed to is a widespread belief that opioid
addiction is untreatable. A lot of news coverage focuses on the dire
statistics about opioid addiction, but not solutions - leading many to think
that the situation is grim and unsolvable. ER doctors also often see
patients with addiction come back after multiple overdoses; that, over time,
makes them jaded about whether these people are actually getting better.
But treating addiction also requires acknowledging that setbacks can happen
and are even common. After Curci's first visit to the emergency room that
got him into treatment, he entered a 90-day residential program. Once he got
out, he got a job, a car, and his own place to live - all things he could
never hold onto before. But a few months in, Curci said, he messed up -
letting his ex-girlfriend, who was using heroin, back into his life. That
led to a relapse.
Relapse is common for all sorts of chronic conditions, from cancer returning
after remission to a sudden depression episode after years of a calm mind.
Relapses with other diseases can even be caused by patients' actions - like
the patient who continues eating too many hamburgers despite heart disease,
or the person who takes her insulin improperly and has her diabetes flare
up. Yet health care providers wouldn't let patients suffer just because they
messed up.
"We don't say, 'Okay. You didn't take your insulin right, so I'm not going
to prescribe it anymore. I'm going to let you die right here,'" D'Onofrio
said.
To address these misconceptions, ER leaders emphasize the successes. "Once
we have a patient that works well, I will go back to the nurses and say,
'Hey, it was really great that so-and-so came in and we got them in
treatment, and they are still in treatment,'" Moulin said. That makes
doctors and nurses "feel like they made a difference," Moulin added.
Sometimes, convincing staff that treatment works is as simple as getting
them to do some treatment on their own. Sampson, of the Marshall Medical
Center, told me about a patient who came in miserable, in withdrawal from
opioids. Within 30 minutes of administering buprenorphine, the patient was
visibly better - looking, in Sampson's words, "human." He got signed up into
treatment after that.
At the end of it all, the nurse working with Sampson at the time, once a
skeptic of buprenorphine treatment, told her, "We saved that person's life.
That was remarkable."
Policymakers could do more to support addiction treatment
If there was a universal complaint among the people I talked to, it's that
different levels of government aren't doing enough to support ER-based
addiction treatment. In some cases, governments are even standing in the
way.
Within emergency rooms, a consistent concern is all the regulations around
prescribing buprenorphine. There is a special rule that allows providers in
the ER to administer - but not prescribe - buprenorphine for up to 72 hours,
particularly to treat withdrawal. But if a patient requires a longer-term
prescription to tide them over before a follow-up appointment, providers
have to be able to prescribe buprenorphine - and overcome all the hurdles
that proper certification requires.
The providers I spoke to acknowledged that some regulations around
buprenorphine are needed, since it's an opioid that can be diverted for
misuse. But the training requirements add an extra hurdle - one that doesn't
exist for medications for other medical conditions - that can prevent
providers from treating addiction. And the strict regulations may even be
self-defeating, since research suggests that the biggest reason people turn
to illicit means of obtaining buprenorphine is a lack of legal access to it
for addiction treatment.
The broader problem, though, is the lack of government support for addiction
treatment in general. Over the past few years, the federal government has
approved new funding here and there in response to the opioid epidemic that
is going to addiction treatment. Some of that money has benefited the
California ER program.
But the funding falls far short of the tens of billions that experts
estimate is necessary to fully confront the opioid crisis. Not only that,
but the new funding programs are typically limited grants, which will expire
in a few years and only fund programs on the ground for one or two years at
a time.
Imagine how this works for the ER program: You may not get enough funding to
do the whole program to begin with, particularly to support not just the ER
side of things but also the providers and clinics that will do follow-up
appointments. Then, the funding will be limited to one or two years. So
you're starting this program that will presumably involve some costs for
years to come, but the limited funding is only guaranteed for one or two
years.
This is why experts have consistently told me that funding levels not only
need to be much higher, but sustained over the long term, too. Wakeman,
Flynn, and others invoked the Ryan White Care Act, passed in response to the
HIV/AIDS epidemic, as a model; that law set up a permanent federal program
that directs funding to ensure just about everyone can access HIV/AIDS
treatment. There are also changes with health insurance programs, such as
those Virginia took with Medicaid, that could ensure insurers not only pay
for addiction treatment, but do so at rates that actually cover the costs of
treatment.
Only once such steps are taken can the massive coverage gaps found in
federal reports, from the surgeon general's to the White House opioid
commission's, start to really close.
This extends to other kinds of addiction and other types of addiction
treatment, beyond medication, too. In my time at the ER in UC Davis, I saw
multiple cases that involved drugs besides opioids - particularly alcohol,
which is linked to more deaths each year in the US than all drug overdoses
combined. Better care is needed in these other areas as well.
"We're working hard to not create a one-drug system of care," Kelly Pfeifer,
director of the High-Value Care Team at the nonprofit California Health Care
Foundation, told me. "We're trying to use the money and attention to the
opioid epidemic to support our efforts to build a robust addiction treatment
structure that is integrated with our health care system so that any person
with addiction can get the care they need."
That, at least, is the hope, even if it's far from what the US does today.
"Everything we're talking about is what we do for every other health
condition," Wakeman said. "This is really just bringing addiction treatment
into the medical mainstream."
The good news is that if this work is done, we may start to see fewer
stories about all the overdose deaths each year and instead see more stories
like Michael Curci's.
Back at El Dorado County Community Health Centers, Curci reiterated how
grateful he was for California's ER program - the hope it gave him, after a
life of feeling like he had little to look forward to. He reflected on
reconnecting with family and friends, working, getting his own place and
car, and the possibility of going to college.
"I know I'm going to get this right," Curci said. "Because I'm going to do
everything in my power to get this right. I do not want to be that person
again."
Brian Potts MD, MBA
Managing Editor, CAL/AAEM News Service
Contact us at: <mailto:calaaem.news.service1 at gmail.com>
calaaem.news.service1 at gmail.com
For more articles, visit our
<https://www.aaem.org/get-involved/chapter-divisions/calaaem/news-service>
archives.
<mailto:somcaaem at uci.edu> To
<https://maillists.uci.edu/mailman/listinfo/calaaem> unsubscribe from this
list, visit our mail server.
Copyright (C) 2018. The California Chapter of the American Academy of
Emergency Medicine (CAL/AAEM). <http://www.calaaem.org/>
http://www.calaaem.org. All rights reserved.
CAL/AAEM, a nonprofit professional organization for emergency physicians,
operates the CAL/AAEM News Service solely as an educational resource for
physicians. Dissemination of an article by CAL/AAEM News Service does not
imply endorsement, agreement, or recommendation by CAL/AAEM News Service,
CAL/AAEM, or AAEM.
Follow CAL/AAEM on Facebook and Twitter and check out WestJEM:
<http://www.facebook.com/CALAAEM> <https://twitter.com/CALAAEM>
<https://westjem.com/>
-------------- next part --------------
An HTML attachment was scrubbed...
URL: <http://maillists.uci.edu/pipermail/calaaem/attachments/20190110/9b841df4/attachment-0001.html>
-------------- next part --------------
A non-text attachment was scrubbed...
Name: image001.jpg
Type: image/jpeg
Size: 14160 bytes
Desc: not available
URL: <http://maillists.uci.edu/pipermail/calaaem/attachments/20190110/9b841df4/attachment-0004.jpg>
-------------- next part --------------
A non-text attachment was scrubbed...
Name: image002.jpg
Type: image/jpeg
Size: 982 bytes
Desc: not available
URL: <http://maillists.uci.edu/pipermail/calaaem/attachments/20190110/9b841df4/attachment-0005.jpg>
-------------- next part --------------
A non-text attachment was scrubbed...
Name: image003.jpg
Type: image/jpeg
Size: 919 bytes
Desc: not available
URL: <http://maillists.uci.edu/pipermail/calaaem/attachments/20190110/9b841df4/attachment-0006.jpg>
-------------- next part --------------
A non-text attachment was scrubbed...
Name: image004.jpg
Type: image/jpeg
Size: 2533 bytes
Desc: not available
URL: <http://maillists.uci.edu/pipermail/calaaem/attachments/20190110/9b841df4/attachment-0007.jpg>